Medical Oncology
Physician insights on cancer treatment protocols, immunotherapy, targeted therapies, and clinical trial updates.
Recent Discussions
How do you incorporate Oncotype or Mammaprint recurrence score when planning an adjuvant CDK4/6 inhibitor for high-risk early-stage HR+ breast cancer?
Oncotype DX and MammaPrint recurrence scores are not used to guide adjuvant cyclin-dependent kinase 4/6 (CDK4/6) inhibitor therapy in high-risk, early-stage, hormone receptor-positive breast cancer. However, they were used to further identify the node-negative patient population with T2 or greater t...
What factors do you use to decide between ribociclib and abemaciclib for high risk HR+/HER2− early breast cancer?
For women who are eligible for both, we discuss both, but I am biased towards ribociclib for certain. The QOL issues we have had with abemaciclib in the adjuvant setting have been outrageous. Despite best supportive care and dose adjustments, I have women severely limiting their daily activities aro...
How would you manage a CVST secondary to a traumatic brain injury with the presence of intracranial hemorrhage?
When dealing with CVST after TBI, the mechanism of injury is not the same as a spontaneous CVST. There is often direct injury to the vein or the area overlying it. Given that these patients often have other traumatic injuries, and given the lack of clear evidence to support one therapy or another, I...
When, if ever, will you utilize T-DM1 in metastatic HER2+ breast cancer given trastuzumab deruxtecan's significantly improved efficacy vs T-DM1?
We now have very compelling data that trastuzumab deruxtecan (T-DXd) is highly effective in the second line setting and superior to T-DM1. The announcement of results came with the statement that "this study will lead to a paradigm shift in the treatment of Her2-positive metastatic breast cancer". S...
How do you reconcile the differing results of the C-POST and KEYNOTE-630 trials when discussing treatment options with high-risk CSCC patients?
I explain that the two trials enrolled different risk populations, which likely accounts for the apparent discrepancy in outcomes — but when you look closely, they actually lead to the same clinical conclusion. C-POST deliberately enriched for very-high-risk patients (using well-established adverse ...
How would you treat a patient with Gleason 8 or 9 prostate cancer, pretreatment PSA 15-24, with retroperitoneal adenopathy?
I would offer a similar approach to that described nicely by @Dr. First Last and @Dr. First Last: definitive RT+ADT+abiraterone, with SIB to the grossly positive nodes. My caveats and additions are: I start with a frank discussion with the patient re: evidence for various scenarios and general prog...
Would patients receiving targeted therapies be eligible for TTFields for brain metastases?
It is unknown whether NSCLC brain patients receiving targeted therapies should also receive TTFields. The most common patients would be those harboring EGFR mutations or ALK rearrangement. This would need to be studied and should not be presumed to be safe, as other unforeseen toxicities have occurr...
How would you manage a patient with non-mutated oligometastatic NSCLC with a brain met who underwent resection of the brain met, had 4 cycles chemoIO, and had resection of the primary lung CA with pCR and now is NED?
This is a great question, and this scenario does come up occasionally within our Thoracic Tumor Boards. What makes this scenario more complicated is the integration of immune checkpoint inhibitors into standard practice. However, this question has been addressed in the pre-immunotherapy era with num...
What is your preferred approach for managing oligoprogressive NSCLC during second-line or later systemic therapy if patient is otherwise responding well at other sites of disease?
I would offer metastasis-directed therapy with SBRT or if necessary based on site, hypofractionated (8-15 fractions) RT to oligoprogressive disease in this setting which we now have Phase 2 randomized data to support due to the nice work of Dr. @Dr. First Last and her team in the CURB trial. Patient...
What adjuvant treatment would you give to a locally advanced esophageal adenocarcinoma status post neoadjuvant FLOT s/p resection with positive margins?
For an R1 resection, considerations would include re-resection if feasible or chemoradiation. I would not favor chemotherapy unless there was evidence of a really convincing response from FLOT. I assume MSI testing was done.